Why are fewer affected men identified in formal treatment settings? One possible explanation is that men simply do not see themselves as being at risk, and therefore dismiss or ignore symptoms that might be indicative of an illness requiring treatment. For example, a young woman who is overeating and vomiting would be quite likely to self-identify as having bulimia nervosa, due to the large amount of public attention that has been paid to these conditions. A young man with similar symptoms might simply think that his eating habits are bad or that he drinks too much, not paying too much attention otherwise. Friends-both male and female-might also have a lower index of suspicion for a formal eating disorder and attribute symptoms to other causes.
A young man who is losing weight might be identified as having a drug problem or AIDS, rather than suffering from anorexia nervosa. Again, neither male nor female friends might make the connection between the outward symptom and the presence of an illness, simply because of the societal expectation that individuals with eating disorders are all female.
The relevant message for clinicians is to be aware that men are at risk for eating disorders and to include a history of eating-related behaviors in their exams. This is particularly important in the identification of bulimia nervosa, which may have no outward symptoms.
Men may also be worried about assumptions about sexual orientation. There is a long controversy about the extent to which homosexual men might be over-represented among those males with eating disorders. To date, all the research done on this question has been in clinical samples and may be biased. Studies from these clinical populations have cited high rates of homosexual orientation (Herzog et al., 1984). Unfortunately, information on sexual orientation was not available for the Woodward et al. (2001) study. We are attempting to discover whether this information is available for the Health Canada (2003) study. Thus, there is no definitive answer to the question of sexual orientation and eating disorders.
One idea that has been raised to explain these findings is that homosexual men may be less reluctant to self-identify as suffering from an eating disorder because of the different focus on weight and shape in the homosexual male community. They may also simply be more willing to access treatment once they have identified their behaviors as troublesome. For the clinician, the most important issue to remember is to reassure heterosexual male patients that the diagnosis of an eating disorder does not require any specific sexual orientation and that no assumptions will be made about sexual orientation, one way or the other.
Men may be unwilling to enter treatment programs that are mainly for women. There is a fairly good awareness among both men and women about the extent to which eating disorders are a problem for women, which includes the idea that all available treatment programs are for women only. Alternately, men may experience a general reduction in help-seeking behaviors that is independent of diagnosis. I am unaware of any treatment programs specifically for men, aside from an occasional support group. Unfortunately, the lack of male-specific treatment programs reinforces the idea that treatment is only for women.
I am equally unaware of significant programs that exclude men. The reduced focus on treatment of men is usually related to the small number of men presenting for treatment--so a circular arrangement occurs. While there is little formal research on treatment outcome for men, most senior clinicians will indicate that the outcome appears to be similar for both men and women. I tell prospective male patients that the usual role a male patient ends up taking in a treatment group is that of a brother--someone the female patients trust and feel close to, but with whom there are clear boundaries. In my treatment programs, men are included in all aspects of the program when admitted. In fact, our female patients have told us that they appreciated having a male peer's input on issues pertaining to relationships, appearance and so forth.
For the clinician, the most important messages for male patients are that the treatment is the same for men and women and that men are generally welcomed, both by the treatment team and by other members of the treatment group. It is worth reassuring a male patient that he is likely to be accepted by the group and will find a comfortable place there.